Dealer Application Form
INSTRUCTION:
1. Fill the form out in its entirety (all 3 pages)
2. Verify and print out form
3. Sign authorized signature on line indicated
4. Fax completed form to us at 703-922-0032
Customer Information
Legal Name:
Billing Address:
Street:
Suite:
City:
State:
Zip:
-
Country Origin:
Telephone:
( ) - -
Fax:
Email:
Shipping Address:
Street:
Suite:
City:
State:
Zip:
-
Country Origin:
Telephone:
( ) - -
Fax:
Email:
Name of Business Trading As:
Name of Parent Company (optional):
Address:
City:
State:
Zip:
Nature of Business: (check all that apply)
Retail
E-commerce
Wholesaler
Distributor
Type of Business:
Corporation
Partnership
Proprietorship
Date Established:
/
Estimated Annual Sales:
Number of Employees:
Federal Tax I.D. Number:
(or Social Security Number)
State:
State Tax I.D. :
Name and Title of Principal Owners or Officers:
[1]
Name:
Title:
Address:
City:
State:
Zip:
Phone:

[2]
Name:
Title:
Address:
City:
State:
Zip:
Phone:

[3]
Name:
Title:
Address:
City:
State:
Zip:
Phone:
BANK REFERENCES:
[ Bank 1: ]
Name:
Title:
Address:
City:
State:
Zip:
Account:
Phone:

[ Bank 2: ]
Name:
Title:
Address:
City:
State:
Zip:
Account:
Phone:

[ Bank 3: ]
Name:
Title:
Address:
City:
State:
Zip:
Account:
Phone:
TRADE REFERENCES:
[ Business 1: ]
Name:
Title:
Address:
City:
State:
Zip:
Account:
Phone:

[ Business 2: ]
Name:
Title:
Address:
City:
State:
Zip:
Account:
Phone:

[ Business 3 ]
Name:
Title:
Address:
City:
State:
Zip:
Account:
Phone:

  NAME: _________________________________TITLE:_________________
 

  SIGNATURE: ____________________________Date: __________________
 
OFFICE USE ONLY SeaGateFilters, Inc. Approved Account Number: __________